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Fillers beef up botulinum results, physician says

Boston — Botulinum toxin combined with fillers produces synergistic results, says Timothy Corcoran Flynn, M.D.

"Aging is caused by photodamage, hyperactive muscles and volume loss. By combining botulinum (toxin) and fillers, you attack the problem on two of the three fronts. Botox eliminates the muscular hyperactivity that causes wrinkles or enervation, and fillers restore the volume loss," says Dr. Flynn, clinical professor of dermatology at the University of North Carolina in Chapel Hill and medical director at the Cary Skin Center in Cary, N.C.

He cites a recent study by Drs. Jean and Alastair Carruthers et al, published in Dermatologic Surgery, concluding that combination therapy with botulinum toxin and fillers has another benefit: It produces much longer-lasting results than either fillers or toxin used alone, when used to treat folds and furrows of the glabella.

Other dermatologists have moved beyond the glabella, using combination therapy to treat the lips and other facial areas.

Dr. Flynn says the Cary Skin Center is independently conducting studies to investigate the use of combination therapy for treatment of the perioral area.

"We fill the corners of the mouth and also concomitantly use botulinum toxin in perioral muscles. Particularly helpful is the injection of botulinum (toxin) into the depressor anguli oris with its origin in the mandible and its insertion point at the corner of the mouth.

"Botox used as a sole agent results in the corners of the mouth being elevated. The combination of fillers plus botulinum toxin periorally has been done now for several years, and patients are now coming back and routinely requesting the combination procedure. It produces a wonderful effect," he says.

Dr. Flynn particularly likes to use hyaluronic-acid derivants as medium-depth fillers, topped by collagen products — Zyderm (Inamed), which is bovine-derived, and CosmoDerm (Inamed), which is derived from human cell lines — for superficial fine lines.

This addresses another problem dermatologists sometimes run into when using hyaluronic acid derivatives superficially:These fillers can produce small, subcutaneous nodules and imbue the skin with a blue color. Topping with collagen, which is whiter and softer, makes the presence of fillers more difficult to detect.

To get good results with botulinum toxin, dermatologists have to pay attention to a patient's individualized anatomy and devise a case-by-case injection strategy, rather than going by the textbook. Also, patients who come in with an altered anatomy due to a brow lift or blepharoplasty require extra attention because muscles may not be positioned in the usual locations.

Occasionally Dr. Flynn is referred a patient who is described as "resistant" or a "non-responder." The solution, often, is to use more botulinum toxin.

Referring to research conducted by the Carrutherses, Dr. Flynn says: "Dermatologists need to use more product when treating big, beefy guys who have a lot of muscle mass ... in the male glabella, you can use significantly more botulinum toxin — 60 to 80 units."

To minimize pain, Dr. Flynn uses a U100 insulin syringe with a sharp needle. To minimize bruising, he asks patients to stop taking aspirin, vitamin E and herbal supplements, such as ginko, a couple of weeks prior to treatment.

Disclosure: Dr. Flynn has done consulting and research and owns common stock in Allergan. He has done research and has been a consultant with Elan Biopharmaceuticals, and has participated in research with Inamed.

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